Healthcare Provider Details

I. General information

NPI: 1598052458
Provider Name (Legal Business Name): KATHLEEN E MISEK P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN E ELLIS P.A.

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 1010
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1725 W HARRISON ST SUITE 1010
CHICAGO IL
60612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5904
  • Fax: 312-563-2371
Mailing address:
  • Phone: 312-942-5904
  • Fax: 312-563-2371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-003607
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: